Alcohol + Substance Misuse Flashcards
List the different types of ‘disorders/states’ seen in substance misuse (6) (THAWDD)
Acute intoxication Harmful use Tolerance Dependance syndrome Withdrawal state Drug-induced psychosis
What are the core features of Dependance syndrome
Primacy (most important thing + relationships etc suffered)
Tolerance
Withdrawal
Rapid reinstated dependance after abstinence
Continued use despite -ve consequences
Loss of control
Narrowing of repertoire (range → one + same setting)
What % of: drink daily?
a) 16-25yrs
b) 25-45yrs
c) 65+ yrs
What % of men + women are alcohol-dependant in UK?
a) 1%
b) 4%
c) 13%
Men: 9%
Women: 4%
What proportion hosp admissions related to alcohol?
What proportion violent incidents in pub/club
What proportion RTAs from drinking?
2/3rd hosp admissions related to alc
1/5 violence in pubs/clubs
1/6 RTAs from drink driving
What are the Bio (2) - Psycho (1) - Social (5) RFs for Alcohol Misuse Disorder?
Bio: Genetic role (alc metab) 1st degree = 7x risk (even if adopted)
Psycho:
Any mental illness
(Stress / Social Anxiety / Low-Self Esteem associated)
Social: Men Low socio-economic class Loss of spouse Social isolation Certain professions
List the neurological complications with alcohol misuse (7)
Cognitive/memory impairment Cerebellar dysfunc Reduced brain wt/vol Wernicke-Korkasoff Central pontine myelinolysis (quadriparesis)
Peripheral neuropathy/myopathy
Optic nn atrophy
List the Resp (2) + CV (4) complications with alcohol misuse
Infection susceptibility
Aspiration susceptibility
Alcoholic cardiomyopathy
Arrhythmias (esp AF)
CVA (esp haemorrhagic)
HTN
List the Hepatic complications of alcohol misuse (4)
Fatty liver changes in 90% (can occur after 1 binge - reversible w. abstinence)
Alcoholic hepatitis
Cirrhosis as end-stage (fast progress if female/HepBC)
Hepatocellular Carcinoma
List the Renal (2), Pancreas (2) + Spleen (1) complications of alcohol misuse
Renal:
Cirrhosis → hepato-renal syndrome
HTN → CKD
Pancreas: Acute/Chronic Pancreatitis
Spleen: Splenomegaly from cirrhosis/portal HT
What are the GI complications of alcohol misuse (3:3:3)
Oesophageal: M-W tears / Varices / Barretts
Gastric: Gastritis / Ulcers / Carcinoma
Intestinal: Malabsorp / Chronic diarrh / Colorectal cancer
What are the reproductive complications of alcohol misuse (3F/2M)
Female: Sexual dysfunc / subfertility / pregnancy risks
Male: Erectile dysfunc / hypogonadism
List some psychiatric complications of alcohol misuse (6)
Substance-induced psychosis (rare/reversible)
Alcohol-Related Brain Damage
Pathological jealousy (monosymp delusion)
Anxiety/Depression (self-medicate / depressant / withdrawal-anxiety)
Scz: associated incidence
Higher risk of: relapse / non-concordance / violence
Suicide: higher risk, esp if: social isolated / many failed abstinence attempts / psych co-morb
What are the social complications of Alcohol Misuse (6)
Marital disharmony/divorce
Psychological harm to family
Physical harm /domestic violence
Risky sexual activity
Impact on employment
Financial/legal problems
What are the RFs for more severe alcohol withdrawal (5)
Amount alc consumed**
Length time been heavy drinking**
Previous withdrawal
Advanced liver disease
Intercurrent medical illness
In what timeframe does mild/uncomplicated AWS (alc withdrawal syndrome) occur?
4-12hrs after
Last 2-5d
What are the symptoms of Mild/Uncomplication AWS (I CANT SIPP)
Intense alc craving
Coarse tremor
Anxiety
N+V
Tachycardia
Sweating
Insomnia
Psychomotor agitation
Poss transient hallucinations
In what timeframe do alc withdrawal seizures occur?
What is their incidence?
6-48hrs after
5-15% get grand-mal seizures
What are the RFs for withdrawal seizures in alc misuse? (4)(HHIP)
H/o head injury
Heavy/prolonged alc consumption
Idiopathic epilepsy
Previous withdrawal seizures
In what timeframe do delirium tremens occur?
What incidence ?
1-7d after
5% AWS
List a DDx for delirium tremens (3)
Head injury
Encephalopathy (Hepatic/Wernicke)
Alternative cause of delirium
What are the Sx of delirium tremens (8)
In addition to Uncomplicated AWS Sx:
Disorientation Altered consciousness Amnesia Hallucinations Severe psychomotor agitation / tremor Autonomic disturbance Fever Electrolyte imbalance
What are the key components for alcohol detox Tx (3)
Symptomatic relief with BZDs (reducing regime w. chlordiazepoxide)
Nutritional/vitamine supplementation (thiamine + multivit)
Close monitoring of complications
Describe the pathophysiology behind Wernicke’s encephalopathy
Neurodegeneration from thiamine defc
Haemorrhages + secondary gliosis in grey matter (periventricular/periaqueductal)
List the causes of thiamine defc (4)
Chronic alc misuse***
Anorexia nervosa
Post-GI surgery
Hyperemesis gravidarum
Why are alcoholics particularly prone to thiamine defc? (3)
- Poor diet
- Reduced GI absorption
- Reduced hepatic storage capacity (co-existing disease)
What is the classic triad of Sx in Wernicke’s encephalopathy (AAO)
+ any other associated Sx (3) (PRN)
Acute confusional state (80%)
Ataxic gait
Oculomotor (nystagmus/ophthalmoplegia)
Peripheral neuropathy
Resting tachycardia
Nutritional defc stigmata
What is the prognosis like in Wernicke’s encephalopathy (mortality / progression)
15% mortality if untreated
80% progress to Korsakoff syndrome
How is Wernicke’s encephalopathy managed? (2)
What should not be done / caution when treating?
IV High potency thiamine (VitB1) replacement (Pabrinex)
Treat co-existing AWS
NB do not rehydrate with glucose solution before thiamine as will exacerbate
What are some causes for Korsakoff syndrome (4)
Thiamine defc
Head injury
Encephalitis
CO poisoning
What are the clinical features of Korsakoff syndrome (4)
Anterograde amnesia (marked) Retrograde amnesia (slight) Confabulation (false memories where amnesic) Apathy
Describe the bio-psycho-social management of Korsakoff syndrome
Bio: treat any Wernicke’s / oral thiamine + multivit (2yrs)
Psychosocial: e.g. OT input, carer support (for cognitive impairment)
What is the prognosis like in Korsakoff syndrome?
50% no recovery
25% signif recovery over time
25% complete recovery
List the main headings in taking an Alcohol History
ALC Stops The Pain
Screening (CAGE)
Attempts stopping
Lifetime pattern of alc consumption
Current alc consumption
Social/occupational probs
Tolerance/Dependance/Withdrawl
Physical/Mental health
What may be seen physically O/E in an alcoholic?
Poor general condition AWS symptoms Facial capillarisation Liver disease stigmata Peripheral neuropathy Cerebellar signs
What Ix can be done when assessing alcohol misuse? (3)
MCV - high specificity (stays high 3-6m post-abstinence)
GGT - more specific < other LFTs
Liver USS
What is the MOA of heroin?
Crosses BBB → mu agonist → inhibs GABA release
→ less inhib effect / increased release dopamine
→ continued activation of dopaminergic reward pathway
What are the harmful effects of heroin via all routes (4)
Constipation
N+V
Resp depression
Loss of consciousness/aspiration risk
What are the harmful effects of heroin via IV route? (6)
Local abscess Cellulitis Osteomyelitis Bacterial endocarditis Septicaemia HIV/HepBC transmission
What are the acute (5) + chronic (2) harmful effects of MDMA use?
Hyperthermia Blurred vision Jaw clenching Nausea Comedown (fatigue/depression) 12-48hrs after
Depression/Anxiety Tolerance develops (but not dependance)
What is the MOA of cocaine?
Blocks monoamine reuptake (Dopa/NA/5HT)
Increased dopamine in mesocorticolimbic
What are the acute (3) + chronic (4) harmful effects of Cocaine use?
Acute - CV:
Panic attacks
Tachycardia
HTN / Generalised vasocon (MI/CVA)
Chronic: Septum/sinus necrosis CKD 2o to HTN Pregnancy risks (miscarry/abruption) Psych: panic disorder / GAD / psychosis
What are the withdrawal symptoms with Cocaine? (4)
Craving
Fatigue / diff conc
Anxiety / dysphoria
Muscle aches / tremors
What is the MOA of cannabis?
THC activates CB1 (cannabinoid) receptors
→ assoc w. memory/conc/time perception/exec func
What are the physical effects of cannabis (4)
Increased HR
Increased appetite
Dizziness
Smoking-related pathology
What are the psychological effects of cannabis (3)
Can provoke panic attacks
Can provoke psychotic Sx
Chronic use → dysthymia, anxiety, avolition
What is the MOA of BZDs?
Potentiate effects of GABA
What are the acute effects of BZDs (7)
Intoxication Drowsiness Dizziness/blurred vision Impaired conc Impaired coord Hypotension (if IV) Resp dep (if IV)
What are the chronic effects of BZDs (MDT)
Memory/conc impaired
Depression
Tolerance/dependance if regular use for 3-6wks
What are the withdrawal Sx seen with BZDs (6)
Agitation
Anxiety
Insomnia
Seizures
Delirium
Psychosis
Give some examples of harm reduction strategies in alc/drug misuse (3)
Don’t share / use uncleaned injecting equipment
Use other methods (i.e. not injecting)
Substitute prescribing (methadone)
What are some +ve prognostic factors in giving up alc/illicit drug use (5)
Motivated to change
Supportive fam/relationships
In employment
Drug/alc services
Treatable co-morbid (e.g. dep/anx)
What are some -ve prognostic factors (6) in giving up alc/illicit drug use
Ambivalent to change
Cognitive impairment
Unstable accom/homeless
Unemployed
Repeated failures
Primacy
What are the 4 principles of motivational interviewing
Focus - on habits want to change
Engage - estab relationship
Evoking - belief/motivation to change
Planning - practical steps to change
Describe the Bio (3) - Psycho (6) - Social (3) management of Alcohol Misuse
Bio:
Chlordiazepoxide / Disulfiram (deterrent) / Acomprosate
Psycho:
AA / Drug+Alc services
Indiv Counselling / Motiv Interviewing
CBT / Self-Help
Social:
Housing support
Financial/employment support
Social services / child care
What drugs are available for opiate dependance (3 + 2)
Detox - Sx relief of withdrawals:
Lofexidine
Loperamide / Metoclopramide (anti-emetics)
Substitute - long-term as alternative:
Methadone
Buprenorphine
